Changing the Face of Nursing

By Andrew Schwartz on March 17, 2008
Raymond Phillips pauses often when he speaks. His voice is quiet, more the reflective academic he is now than the commander in the Navy Nurse Corps he was before retiring in 2003 from 20 years of service across three branches of the armed forces. A PhD degree candidate at the UCSF School of Nursing, Phillips recently became the first nurse to ever receive a prestigious Fogarty-Ellison Fellowship in Global Health and Clinical Research from the National Institutes of Health (NIH). The program supports graduate students for a year of mentored clinical research at an NIH-funded research center in a developing country. Phillips is spending his year at the Y.R. Gaitonde Center for AIDS Research and Education in Chennai, India. Elizabeth Castillo already had a master’s degree in public health and a burgeoning career when she entered UCSF’s Master’s Entry Program in Nursing (MEPN) because she wanted to do direct patient care. “I felt that [by only providing education about things like tobacco and prenatal care,] I couldn’t fulfill my whole purpose with a patient,” she says. After receiving her master’s degree from the School of Nursing’s Family Nurse Practitioner program in August 2007, she immediately received four job offers from rural primary care clinics in the Central Valley, where she makes her home. Castillo chose the Community Medical Centers in Lodi, where the patient population is mostly Latino, monolingual Spanish-speaking farmworkers and families. Deepika Goyal arrived in this country at age 16. After a relatively short-lived marriage and two children, she became a single mom; to support herself, she worked as a medical assistant for 10 years. Inspired by the nurses she would see in her office, Goyal eventually decided to pursue a nursing career. She got an AA degree, and then went on to San Jose State University to get a bachelor’s degree in nursing and a master’s degree in the school’s Family Nurse Practitioner program. In 2004, Goval received a Betty Irene Moore Fellowship to pursue her PhD degree at the UCSF School of Nursing, and graduated in 2007. “People who knew me 10 years ago see me now and say that anything can happen if you put your mind to it,” she says. People like Phillips, Castillo and Goyal are the cream of the crop. They’re smart, committed and compassionate, and have a wealth of real-world experience, making them extremely desirable for any school of nursing — or any graduate school, for that matter. But all three have another quality that makes them valuable to the UCSF School of Nursing: They represent the changing face of California, perhaps the nation’s most racially diverse state. At a time when talk about diversity can be politically sensitive, the School of Nursing has been out-front and outspoken about the need to bring ethnic minorities into nursing as clinicians, educators and researchers because of the school’s belief that nursing should reflect the diversity that increasingly characterizes California and the nation. Some may argue, of course, that a person’s race or ethnicity shouldn’t matter. Others take it as an article of faith that schools should pursue qualified minority candidates, but never stop to question why. The School of Nursing walks a middle ground with a well-developed rationale for why race and ethnicity matter in training health care providers — and a strong commitment to changing the face of nursing. “We know ethnicity matters in the interaction between patients and providers,” says UCSF School of Nursing Dean Kathleen Dracup, RN, FNP, DNSc. “As one of the country’s top-ranked nursing schools and as a state institution in a state with a very diverse population, we have a responsibility to reflect California’s diversity in our students, our staff and our faculty. We can’t do that unless we understand the barriers to minorities coming here and do everything we can to address those barriers.”.

Why Diversity Matters

Judy Martin-Holland, PhD, MPA, RN, CS, FNP, assistant dean of academic services and diversity in the nursing school, recalls her time as a clinical nurse specialist, when she was frustrated by an elderly Vietnamese man with asthma who would often miss his regularly scheduled appointments. Despite using a translator to ensure that the man understood her instructions, Martin-Holland could only get him to show up occasionally for follow-up care. Instead, the man would show up when he did not have an appointment. “I couldn’t figure out what the problem was until I had a conversation with a colleague of mine, a Vietnamese nurse,” says Martin-Holland. The nurse explained that in small villages in Vietnam, the custom was to go to a healer only when you are suffering. If you’re feeling fine, then you don’t go; there is no tradition of routine follow-ups or the type of preventive care that is practiced in the United States. The insight made two things clear to Martin-Holland: First, that the understanding gained by her conversation put her in a better position to help this man; and second, that he might have gotten better care sooner if he’d been able to see a Vietnamese nurse. Castillo talks about how her patients take one look at her and automatically begin speaking Spanish, telling her things they might not tell a provider who doesn’t speak the language. Karen Hill, an entering PhD degree student who recently graduated with a master’s degree in occupational and environmental health, is also clinic manager at Glide Health Services, a faculty-run community clinic that provides care to a mostly homeless, indigent population in San Francisco. She describes how she defused a potentially volatile situation between an emotionally disturbed black patient and two white policemen at Glide. As a result, the man wound up receiving treatment, rather than spending time in jail. Hill is sure there was something in the color of her face — she’s African American — and her way of speaking that made a difference. None of these nurses claims it’s a 100 percent thing. There are many patients who are relatively color-blind, but it’s clear from hearing the stories that there is something in the interaction between patients and providers of the same race or ethnicity that book learning — even years of clinical experience — cannot replace. “As much as we want to pretend that race doesn’t matter, there are things that are particular to a culture, small things that only people from the same culture share,” says Hill. That shared experience also can affect health research, where traditionally the subjects are from the dominant culture and researchers ask questions that reflect dominant cultural values. Being a minority researcher can make a difference because of the perspective a minority researcher brings to the research question. Doctoral student Janelle Sagmiller Palacios, a member of the Confederated Salish and Kootenai Tribes of the Flathead Reservation in northwest Montana, spent most of her childhood on the reservation. Her PhD degree project, “Sharing Stories,” interviews adult American Indian women about their experience as teen moms. “I’m trying to understand the context and how being a young mother affected their overall life,” says Sagmiller Palacios. Her goal is not necessarily to prevent — as is true of most traditional health care research on teen parents — but to find ways to give these women support and to educate health care providers and educators so they can help. “It’s a different line of questioning because of my experiences and where I come from,” says Sagmiller Palacios.

Evolving Effort

The anecdotes lend flesh to numerous studies that attest to the need to diversify the health professions. After issuing his Sullivan Commission Report in 2004, titled “Missing Persons: Minorities in the Health Professions,” former Secretary of Health and Human Services Louis Sullivan told a group in New York: “Without much more diversity in the health workforce, minorities will continue to suffer.” Dracup clearly agrees, as do many of the faculty members at the School of Nursing. “I am surrounded by faculty members who are enormously committed to meeting the need for more diversity,” Dracup says. With strong faculty support, Dracup has taken numerous concrete steps that include locating a dedicated financial counselor in the School of Nursing, lining up donors who can provide students with emergency financial support and, in June 2003, giving the newly appointed Martin-Holland an unambiguous directive: Increase diversity in this School of Nursing. “[Dean Dracup’s] commitment to this is beyond question,” says Martin-Holland. “She recognizes what diversity can add, and it’s one of the most important reasons I’m still here.” That doesn’t mean Martin-Holland has an easy task. Without models who look like them in health care settings and on nursing school faculties — and there aren’t many — it can be difficult for young people of color to imagine themselves in nursing. Yet to ensure that schools of nursing have faculty with people of color, minority nurses need to be encouraged to pursue advanced degrees. Unfortunately, in many minority communities, there’s a limited history of higher education, so it can be intimidating to even consider applying for and financing such an education. Those who are familiar with the process often have options that surpass nursing in both earning power and worldly prestige. To address these concerns, the School of Nursing has relentlessly pursued a multifaceted strategy to diversify not just the School of Nursing, but the entire profession. As befits the complexity of the challenge, the effort is constantly evolving, with a wide range of tactics competing for limited financial and human resources.

Acting Locally

The first challenge is to get qualified students to apply to UCSF. Outreach is critical because in many ethnic minority communities, even among those who are most advantaged, there is little known about the career paths nurses can follow. “One of my sisters, who went the medical school route, told me that if she’d known more about nursing, she might have made a different choice,” says Castillo. “It takes face-to-face meetings to establish relationships with people and institutions,” says Martin-Holland. It’s a time-consuming, labor-intensive process that demands knowledge and considerable charm. So it’s not surprising that Martin-Holland is good at it. She laughs easily, looks you in the eye and speaks with an earned wisdom, having negotiated environments that range from hospital clinics to academia to politics as a former president of the California chapter of the American Nurses Association. One thing she has done is begin building relationships with a number of traditional black colleges, including Spelman and Morehouse colleges in Atlanta and Howard University in Washington, DC. This year, she successfully recruited two students from those institutions. One will enter the MEPN; the other will pursue a PhD degree. Martin-Holland also is establishing relationships at UC Merced and UC Riverside, both of which have large Latino populations. UC Merced also has a strong representation of Hmong and Vietnamese people, two cultures that are growing fast in California. Martin-Holland also makes the rounds of local hospitals, establishing or building on relationships UCSF has in the hope that some of the RNs at these facilities might be interested in pursuing an advanced degree. Still, says Martin-Holland, “We have no idea how much outreach we need to do. Because there’s a shortage of faculty, nursing schools have huge waiting lists [about 14,000 potential students]. And we don’t know if there are plenty of minority applicants who may be experiencing barriers for entry related to the faculty shortage, or if the pool is more homogenous than expected. We need better information on nursing school applicant pools.”

Understanding the Application Process

Getting students interested is step one. Helping them negotiate the application process is another important piece, which is partly why the School of Nursing runs its Summer Academic Enrichment Program (SAEP). The program helps students of color prepare to go to any top-ranked graduate school. It accepts about 20 students each year, for four to five days on the UCSF campus; about 85 percent of those who attend the program wind up applying to UCSF. Joanne Chien was one of those students. Born in Taiwan, Chien arrived in the United States at age 16. After attending high school in Cupertino, she went to UC Davis, then on to nursing school at San Jose State University, graduating in 2005. Immediately after graduation, she began her current job working as a nurse in the organ transplant unit at Stanford Hospital. “A lot of faculty members at San Jose State were graduates of UCSF, and they were role models to me,” she says, “always talking about how important education is.” In 2004, Chien saw a flyer at San Jose State about the SAEP and wound up attending that summer. “They introduced us to the master’s program in nursing at UCSF and invited us to graduation,” says Chien. “I wanted to be one of those graduating students.” With a lot of encouragement from Martin-Holland and from Lynda Mackin, who coordinates the gerontological nursing master’s specialty, Chien wound up applying to and entering the gerontological nursing master’s program in 2006. “It really shows how great the support here is from the beginning,” says Chien. “It is always special and individualized, no matter what color you are, which country you are from or what language you speak.” For PhD degree students, Karen Hill talks about UCSF connecting her with a UC program called the Minority Training Program in Cancer Control Research, a five-day training for master’s-prepared students who are considering a PhD degree. “The whole goal was to talk about why, as a minority, it was important for you to consider a career in research, with a lot of practical advice for how you can fund your education and how to write your applications,” says Hill.

Navigating Academia

Once through the doors of academia, however, the experience can be unfamiliar and intimidating for people who are just beginning to see themselves as deserving of this level of education. When students of color look around and don’t see students or faculty who look like them — if they don’t have a mentor who can help them through academic rough spots or the constant juggling act of work, education and family — they may not stick around for long. This challenge too is on the school’s radar screen. With Martin-Holland’s encouragement, UCSF has become a strong supporter of the National Coalition of Ethnic Minority Nurse Associations (NCEMNA). Made up of five national ethnic nurse associations (Asian American/Pacific Islander Nurses Association, National Alaska Native American Indian Nurses Association, National Association of Hispanic Nurses, National Black Nurses Association and Philippine Nurses Association of America), NCEMNA has goals that parallel the School of Nursing’s hopes of diversifying the profession, from clinical sites to research settings, and of creating a health care culture that will more effectively address health disparities. For the last three years, NCEMNA has held an annual conference that among other things has paired young scholars, including UCSF students, with prominent mentors through a program called the Aetna/NCEMNA Scholars Program. Raymond Phillips and Janelle Sagmiller Palacios are among those who have attended the conference as mentees; many other UCSF students have attended the conference with UCSF financial support. “These types of conferences can really change individuals,” says Martin-Holland. “Sometimes it’s just a matter of comfort level, of barriers coming down, of an unspoken understanding and shared experience that changes the types of conversations you have.” “Seeing another faculty member who is black makes a difference,” says Phillips. “When you’re in that first year or two of your program, it’s proof positive that it can be done. A conference with your peers can help you navigate through the process.”

Enriching the Curriculum

Beyond providing mentoring and helping students connect with other minority students and faculty, the school also is tackling the hard work of infusing the classroom and the curriculum with a perspective that makes ethnic minority students believe this is an institution that cares about both health disparities and the challenges ethnic minority students face. To that end, the faculty Diversity in Action Group (DIVA) recently conducted a study that looked at the curriculum of every course taught in the School of Nursing, while also conducting a survey of graduating master’s students to determine which classes helped prepare them for working with a diverse population. Among the findings: Students of color notice that the UCSF population could still be more diverse. Nevertheless, they sense the administrative commitment — the willingness to look at processes and make changes where needed. “The response [to the report] from the faculty was mostly positive,” says Martin-Holland. “People tell us that it improved their knowledge and identified some gaps, including the need for more training in how to handle what can be sensitive discussions about race and culture.” DIVA is now in the process of creating a program to give faculty members those skills. Inevitably, part of what makes an institution more hospitable to minority students is informal, perhaps unspoken. “I remember [faculty member] Catherine Waters organized a dinner party for students of color to meet other doctoral students [and prospective doctoral students], where they talked about how they got through the process, the changes they needed to make and so on,” says Hill. “But more than that, the entire faculty, regardless of race or ethnicity — Barbara Burgel, Marion Gillen, Julia Faucett, Judy Martin-Holland, Catherine Waters and more — was always encouraging me to continue with my education.” “There were a lot of Latinas in the FNP program,” says Elizabeth Castillo, “and this seemed important to me because it’s what’s needed in so many family and community clinics. But even where there were fewer Latinas, you could tell that people like [faculty member] Barbara Hollinger have a real passion for, and feel comfortable in, underserved areas.”

Reaching Out

For Castillo, though, the efforts at diversity can’t stop at the doors of UCSF because the pool of candidates needs to widen and UCSF can play a role. “I’ve been in health care for many years, but you just rarely hear that push for what nursing can do,” says Castillo. She is among those anxious to reach out to young people of color, middle school and high school students who will make up the next generation. So is Sagmiller Palacios. While still in nursing school at the University of Washington, she began a research project to help engage more youths, particularly American Indian youths, in nursing. “American Indian students tend to live in rural areas and are often unfamiliar with the process of even applying for college. It can be difficult to get funding, to leave their family behind, to even know how to apply or look for financial aid. It’s not easy to even ask those questions,” says Sagmiller Palacios. Her project targeted schools throughout Washington state that had large Native American and Latino populations. “Often, if those [Native American] students went to college at all, they went to tribal schools or two-year colleges,” says Sagmiller Palacios. “It’s a much a bigger challenge for them to pursue a four-year degree like a bachelor’s in nursing.” To help, she would give the students a pretest that gauged their interest in and knowledge about nursing. Then, after an interactive PowerPoint presentation she had developed, she would re-administer the test and find she was able to increase both interest and knowledge considerably. Outreach like this can make a difference, especially when done by people of color. After all, Deepika Goyal can see the effect her mere presence has on entering students at San Jose State. “There’s no other [Asian] Indian person on the nursing faculty here, even though Santa Clara has the second largest Indian population in the state. I have heard from students that they like the connection; it makes a difference.”

Making a Difference

With its efforts in all of these areas, the School of Nursing has made some important advances, no doubt. But are they enough? Have the school’s considerable resources and prestige truly begun to change the face of the nursing profession? On its own campus, the answer would seem to be a qualified “yes.” Witness the comment by Goyal that during her time at UCSF, “The diversity issue didn’t come up because this is already a diverse place with diverse faculty, diverse students.” “UCSF afforded me an opportunity I might never have had otherwise,” says Phillips. “What they’ve done for me really elucidates their commitment to serving ethnic minorities.” Yet Dean Dracup, while proud of the advances, believes there is still much more to be done. “Despite our efforts, minorities are still underrepresented in our student body and among our faculty,” she says. “We need to do better.” And no one doubts that there is a need to do better in changing who delivers health care to minority patients across the country. Yet, if Karen Hill is any indication, there are encouraging signs. Though many in her family worked in health care as LVNs and in other ancillary positions, Hill is the first in her family to become an RN, a master’s-prepared advanced practice nurse and now a PhD degree student. She worked hard to achieve those goals, is deeply appreciative of the support she received and is passionate about giving back. “I envision, five to 10 years down the road, working at a community college,” Hill says. “I have this dream of telling young women and men of color that you don’t have to be the best student or have tons of money; you just need a vision of having a different life for yourself. Once people see you have that, they want to help.”

Photo by Elisabeth Fall